Download Medical History Form - Body Enhancement MedSpa

Medical History Questionnaire
What type of problem are you consulting for? _______________________________________________
_____________________________________________________________________________________
Personal Information:
Patient Name:__________________________________ DOB___________________ Date____________
Address_______________________________________________________________Apt #___________
City__________________________________ State _____________________ Zip __________________
Home Phone __(________)____________________Cell Phone __(_______)_______________________
Work Phone __(_________)____________________ Email________________________@___________
Preferred contact number & best time to call
________________________________________________
Occupation ____________________________________ Employer ______________________________
Emergency Contact Name/Phone Number __________________________________________________
How did you hear about us? Radio____ Magazine _____ Newspaper _____ Friend _____ Walk-in _____
Other (please specify) ___________________________________________________________________
Health Information
General:
Age__________ Current Weight lbs __________ Height _________ BMI __________
Date of last physical ___________________ Name of Family Physician ___________________________
Is your general health good? Yes ____ No ____ if “No”, explain _________________________________
_____________________________________________________________________________________
Do you have any allergies to medications, latex, soy, or anesthesia? If yes, please specify and state type
of reaction: ___________________________________________________________________________
_____________________________________________________________________________________
List all medications (oral, topical) & herbal supplements you are taking (prescription and OTC) ________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you take Aspirin, Advil, Motrin, Ibuprofen, or anti-inflammatory medication more than once a week?
If yes please explain. ____________________________________________________________________
Do you smoke? If yes, how many per day for how many years? __________________________________
Do you drink alcohol? If yes, how much and how often? _______________________________________
Are you pregnant, nursing or planning a pregnancy soon? No ________ Yes _________
If yes, how soon? ______________________________________________________________________
Mark your skin type (when exposed to the sun for about 1 hour with no protection):






Always burns, never tans
Always burns, sometimes tans
Sometimes burns, sometimes tans
Always tans
Asian, Hispanic, Mediterranean, Middle Eastern
Black
O
O
O
O
O
O
When were you last exposed to the sun (or a tanning booth)? __________________________________
Do you use self tanning lotions?
___Yes
___No
Are you planning a holiday in the sun?
___ Yes
___No
Have you ever had skin resurfacing, rejuvenation or chemical peels? ___ Yes
Have you ever had treatments for pigmented lesions? ___ Yes
___ No
___ No
Prior treatment (if any) __________________________________________________________________
_____________________________________________________________________________________
Present/Past Medical History:
Have you ever had any of the following (please circle)
Asthma
Autoimmune disorder
Chronic diarrhea
Depression
Heart valve replacement
Heart failure
High blood pressure
Intestinal problems
Lung disease
Multiple Sclerosis
Arthritis
Blood disorder
clotting disorder
Easy bruisability
Heart valve disease
Neuro-Muscular disease
Hepatitis
Keloids
Stroke
Muscular dystrophy
Anemia
Chest pain
Colon problems
Excessive scarring
Heart attack
Mental disease
HIV
Kidney disease
Stomach problems
MVP
Cold sores
Seizures
Diabetes
Excessive bleeding
Irregular heart beat
Liver disease
Thyroid disorder
Migraines
Rheumatic fever
Shortness of breath
Cancer-please list type ___________________________________________________________
List all surgeries or hospitalizations with dates: _______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever had any cosmetic procedures in the past? Please list with dates:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
To the best of my knowledge, the information provided above is true and accurate,
Patient Signature __________________________________________ Date _______________________
Reviewed by: ______________________________________________ Date _______________________
Review comments: _____________________________________________________________________
_____________________________________________________________________________________
Provider Signature __________________________________________ Date _______________________
Consultation Comments _________________________________________________________________
_____________________________________________________________________________________
Fitzpatrick Skin-type Chart
Please circle the answer to each question to determine your skin type.
Score
0
1
2
3
4
What color are your
eyes?
Light blue,
gray, green
Blue gray, green
Blue
Dark Brown
Brown Black
What is your natural hair
color
Sandy red
Blonde
Dark blonde,
chestnut brown
Dark brown
Black
What is your skin color?
(non-exposed areas)
Reddish
Very pale
Pale with beige tint
Do you have freckles ins
the non-exposed areas?
Many
Several
Few
Incidental
None
What happens when you
stay in the sun too long?
Redness, pain,
blistering,
peeling
Burns followed by
peeling
Burns some-times
followed by peeling
Rarely burns
Never has a burn
To what degree do you
turn brown?
Hardly at all
Light tan color
Reasonable tan
Tan very easy
Turn dark brown
Do you turn brown within
several hours after sun
exposure?
Hardly or not
at all
Seldom
Sometimes
Often
Always
How does your face react
to the sun?
Very sensitive
Sensitive
Normal
Very resistant
Never has a
problem
When did you last expose
your body to the sun or
tanning bed?
More than 3
months ago
2-3 months ago
1-2 months ago
Less than 1 month
ago
Less than 2 weeks
ago
Never
Hardly ever
Sometimes
Often
Always
Did you expose the area
you want treatment to
the sun?

Total Score
Fitzpatrick Type
0-7
1
8-16
2
17-25
3
26-30
4
Over 30
5
Light brown
Dark brown
Please read carefully and sign your acknowledgement of our refund and
cancellation policies. It is our desire to give our clients the best possible
service and when we have cancellations without notice, we are left
with time slots that could have been filled by other clients. Thank you
for your cooperation in this matter!
REFUND POLICY
All sales, services, down-payments are NON-REFUNDABLE. You
may transfer your monies to other services; however there will
be no refund.
Cancellation Policy
We require a 24-HOUR NOTICE if you are going to change your
appointment. For changes made with less than a 24-HOUR
notice, 50% of the cost of the procedure will be charged to your
Credit Card; or if the services are prepaid, we will deduct 50%
of the cost of the procedure from your credit balance.
_____________________________
Client Signature
_____/______/______
Date